Dr. Roach: Low LDL with statin doesn’t increase hemorrhagic stroke risk

Keith Roach
To Your Health

Dear Dr. Roach: I’m an 82-year-old man, taking 10 mg of atorvastatin daily. My HDL is 85, and my LDL is 46. I recently read that people with low LDL cholesterol levels might have increased risk for hemorrhagic stroke, like a ruptured blood vessel in the brain. Should I be concerned?

— G.G.

Dear G.G.: A stroke is a brain injury with death of brain cells, with or without symptoms. It can be caused by thrombosis, which is the development of a blood clot in a brain blood vessel; by embolus, which is material, usually a clot, moving into the brain from another location, especially the heart; or by hemorrhage from a ruptured blood vessel in the brain. Only about 13% of strokes are hemorrhagic.

It is true that people with naturally low cholesterol levels are at higher risk for hemorrhagic stroke. However, the preponderance of the evidence shows that treatment with a statin, such as the atorvastatin (Lipitor) you are taking, does not significantly increase risk of hemorrhagic stroke. A 2012 review of 31 studies showed an increase in hemorrhagic stroke rate of 8%, but the result could have been due to chance. In fact, statins reduced the overall stroke risk by about 16%, and overall death rate by 8%: These results were very unlikely to be due to chance.

People at high risk for heart attack are often treated with high doses of statin, frequently with a goal of less than 70. A very low LDL (less than 70) has been shown to decrease the risk of future heart attacks in people with known heart disease more than LDL levels that are less extreme (lower than 100).

Even if there is a small increase risk in hemorrhagic stroke rate from taking a statin like atorvastatin, the reduction in the rates of overall stroke, heart attack and death make statins appropriate for those at high risk for heart disease. I would be more hesitant to use a statin in a person with a previous history of hemorrhagic stroke, especially a person without risk factors for other types of stroke or heart disease. This decision should be individualized based on competing risks.

Age 82, by itself, is not a reason to withhold statins, but it is certainly worthwhile to review medication use in older people to determine which medicines are still appropriate.

Dear Dr. Roach: My wife is a healthy, petite 64-year-old female. She has been terrified of having a colonoscopy for years because of the prep. Last July, our primary physician convinced her to do the Cologuard stool test at home. Unfortunately, the result was positive, described as “Possible presence of colorectal cancer (CRC) or advanced adenoma (pre-cancer).” A colonoscopy was recommended. My wife has tried to do this colonoscopy three times and has failed. She is overwhelmed by the prep in several variations and has trouble drinking a lot of liquids in general. One of the solutions made her nauseous. We’ll keep trying, but there is a chance that she may never complete this colonoscopy. What percentage of people who receive positive Cologuard results get cancer? I’m heartbroken!

— P.S.

Dear P.S.: Among people with a positive Cologuard test, about 4% will have colon cancer; 20% will have advanced precancerous lesions (which can turn into cancer relatively quickly); 31% will have nonadvanced adenomas (which can still develop into cancer, but not quickly); and 45% will have normal colonoscopies.

She should absolutely have the colonoscopy, since her risk is far higher than an average person. There are preparation options with much less fluid, and her doctor might also consider medication to help the nausea.

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